Clinicians must start Choosing Wisely in antipsychotic prescribing

As part of the Choosing Wisely campaign, the American Psychiatric Association has released a list of specific uses of antipsychotic medications that are common, but potentially unnecessary and harmful in some instances. Choosing Wisely is an initiative of the ABIM Foundation. The list identifies five targeted, evidence-based recommendations that can initiate conversations between patients and physicians about what care is necessary.

The APA list includes five recommendations, which include not prescribing antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring and not to routinely prescribe two or more antipsychotic medications concurrently. In addition, the recommendations state that antipsychotics should not become a first choice to treat behavioral and psychological symptoms of dementia and physicians shouldn’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults. Lastly, the APA says that physicians should not routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

The organization developed the Choosing Wisely list after months of careful consideration and review, using the most current evidence and consensus of expert opinion about management and treatment options. A work group of members from the Council on Quality Care developed a proposed list and solicited input from a broad group of APA members and leadership. The APA Board of Trustees Executive Committee approved the final list unanimously.

“Our cautions cover both typical and atypical (second generation) antipsychotics,” says Joel Yager, M.D. and chair of the APA Council on Quality Care. “Substantial differences exist both in the types of adverse effects associated with specific medications. Individual patients also react very differently to various medications. Therefore, clinicians should always be familiar with both the individual medications and their patients’ vulnerabilities to medications before prescribing.”

Presently, more than 80 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the Choosing Wisely effort promoting conversations about appropriate care. During the next year, more than 30 other specialty society partners will release Choosing Wisely lists.

“These ‘Choosing Wisely’ recommendations urge clinicians to avoid routinely prescribing antipsychotic medications in certain circumstances as an initial treatment when other types of effective treatments with fewer adverse effects are available,” Dr. Yager told Med Ad News Daily. “We hope to reduce initial overprescribing. Of course, it’s never a good idea to prescribe higher dosages than are necessary, but here we’re concerned with reducing the types of situations in which some clinicians might routinely prescribe antipsychotic medications as an initial treatment.”

The recommendations are not intended to prevent the use of antipsychotics. “As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care,” said Jeffrey Lieberman, MD, APA President. “The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their healthcare. This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first and patients should be engaged in discussion of the rationale for use and the potential benefits and risks.”

One of the goals in releasing the recommendations is to promote more consideration among clinicians, says Dr. Yager. “We’re hoping to get clinicians to be more thoughtful about their initial use of antipsychotic medications,” he told Med Ad News Daily. “Every patient receiving an antipsychotic medication should be carefully evaluated and monitored in an ongoing fashion, and before clinicians prescribe antipsychotic medications in any of the circumstances we’ve delineated, they should think carefully about alternatives, and understand that patients and their families deserve to be brought into these decisions.”